Building the Right Care Team

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1 Building the Right Care Team Care Team Work Analysis (CTWA) 1 What is a Care Team? An integrated group of professional and clerical staff whose processes and skills enable them to care for the needs of a patient population over time (panel of patients and/or caseload). 2 Horizontal Flow for the Office 3 1

and skills enable them to care for the needs of a patient population over

2 Vertical Flow for the Office Nonpatient Care Work Appointment Work: Direct Patient Care We see schedule We don t see waits Nonappointment Work: Indirect Patient Care 4 How Time is Deployed or Allocated Clinic Meetings Proc ASC OR Hospital Consults/Rounds Call D S D S D S D S D S D S D S Balance Between and Within Each 5 Demand Capacity 39% of Capacity is Physician Time 39% of Capacity is MA Time 22% of Capacity is RN Time 6 2

Meetings Proc ASC OR Hospital Consults/Rounds Call D S D S D S D S D S D S D S Balance Between and Within

3 The Two Most Important Elements in Completing Clinical Care Tasks? Staff doctor vs resident Practice size Provider age Year of graduation from medical school Training Feedback Team 7 Benefits of a Primary Care Team What do you think? 8 Business Case for Care Teams Nursing, administrative, clerical, and aids all independently related to productivity measured by both visits and billing. 1,2 Strong positive correlation between number of support staff and productivity i as measured by visits i per week. 3 Held true for secretaries, RN s, LPN s, and medical technicians Reinhardt U. A production function for physician services. Rev Econ Stat. 1972;54(1): Thurston NK, Libby AM. A production function for physician services revisited. Rev Econ Stat. 2002;84(1): Brown DM. Do physicians underutilize aides? J Hum Resour. 1988;23(3):

8 Business Case for Care Teams Nursing, administrative, clerical, and aids all independently related to productivity measured by both visits and billing.

4 Business Case for Care Teams (cont) Strong relationship between both administrative support staff and medical support staff and physician productivity (as measured by revenue per physician) Pope GC, Burge RT. Economies of scale in physician practice. Med Care Res Rev. 1996;53(4): What Does a Care Team DO? 5 Population management Just in time Minimize steps Patient focus Measures Match activities to demand Links 5. Batalden PB, Mohr JJ, Nelson EC, Plume SK, Baker GR, Wasson JH, Stoltz PK, Splaine ME, Wisniewski JJ. Continually improving the health and value of health care for a population of patients: the panel management process. Qual Manag Health Care. 1997;5(3): Burning Questions How many support staff are needed in our practice? If we decide to hire, what professional type of person is best? How do we use our existing resources best? Others 12 4

5 Population management Just in time Minimize steps Patient focus Measures Match activities to demand Links 5.

5 Medical Group Management Association Cost Survey: 2000 Report Based on 1999 Data Profitability for Family Medicine Groups by Number of FTE Staff per FTE physician FTE Physician Median Revenue after Operating Cost per 300,000 $241, ,000 $227,890 $187, ,000, $176, ,000 $90, ,000 50, FTE Support Staff per FTE Physician Reprinted with permission from the Medical Group Management Association, 104 Inverness Terrace East, Englewood, Colorado Copyright Who Makes Up the Care Team? 14 Group of smiling doctors and healthcare professionals Provider Roles (Continuum) Continuum of function : MD with no nursing staff MD with nonconsistent nurse staffing MD with consistent nurse staffing MD with consistent nurse and clerical staffing Group of providers with consistent RN, MA, and clerical staff 15 Doctor wearing a stethoscope

0 FTE Support Staff per FTE Physician Reprinted with permission from the Medical Group Management Association, 104 Inverness Terrace East, Englewood, Colorado 80112. www.mgma.com.

6 Clerical Staff Roles (Continuum) Scheduler at front desk or in central area Schedules and takes messages for many Scheduler accountable to a group of providers Scheduler actually co-located with the providers and patients they support 16 Woman on phone Clerks Are Important Conrad, analyzing the AMA s Physician s Practice Cost and Income Survey from 1997 found + relationship between weekly hours of clerks per MD and the number of MD visits Conrad DA, Sales A, Liang SY, Chaudhuri A, Maynard C, Pieper L, Weinstein L, Gans D, Piland N. The impact of financial incentives on physician productivity in medical groups. Health Serv Res. 2002;37(4): Nursing Roles (Continuum) Phone calls, rooming, paperwork, triage, scheduling Nurse offers advice over the phone or through Nurse manages populations of patients

Clerks Are Important Conrad, analyzing the AMA s Physician s Practice Cost and Income Survey from 1997 found + relationship between weekly hours of clerks per MD and the number of MD visits. 6 6.

7 What Are the Attributes of a Care Team? Proactive vs reactive Communicative vs isolated Accountable to each other, and to the patient Uses measures for feedback Delivers high quality chronic, acute, and preventive care cross-trained vs territorial Integrated vs separated Continuous flow vs flow based on urgency All staff work to highest level of training, experience, and licensure 19 Foundations of an Excellent Care Team Patient value is key All team members roles & responsibilities should be standardized & clear Each individual is key to team success All team members should know in advance of having to make decisions based on set parameters whether they have the authority & permission to do so. Need reliable communication & process for conflict resolution must be very clear Come up with own examples of staff appreciation 20 Teams: Know Your People Know Your Processes Processes Identification Measurement Mapping Identification People Know each other Teamwork Communication i 21 7

territorial Integrated vs separated Continuous flow vs flow based on urgency All staff work to highest level of training, experience, and licensure 19 Foundations of an Excellent Care Team Patient

8 Optimal Care Teams Rules: Elevate all members of the team to the highest level their education, training, and experience will allow Move work away from the constraint in the system 22 Assure that all work to highest level Determine everyone s highest level; research provincial and government regulations Provide competency training and testing to raise skill levels where necessary Help all become aware of each team member s skills and interests Cross-train where appropriate Empower the team Blood pressure cuff being used during a medical examination Then Divert all unnecessary work away from the provider in a way that: Enhances the patient-provider relationship Promotes trust in the care team Builds the relationship with the care team Provides high quality care

aware of each team member s skills and interests Cross-train where appropriate Empower the team Blood pressure cuff being used during a medical examination. http://office.microsoft.

9 Defining the Work: Examples of Common Processes Referrals Messages Refills Rooming Advice Teaching Order entry Care under protocol registration Records retrieval Billing Phones Authorization Medication Monitoring Scheduling Businesswoman and filing cabinet Job Analysis Survey of 7 practices Extensive interview of provider, nurse, pharmacist, clerk (1 to 2 days) Standardized description of tasks 243 tasks identified 26 Task Categories Administrative Scheduling, phones Prevention Education, treatment Treatment Medication, procedures Diagnosis History, Physical, ordering & interpretation of tests Relationship Primary Care Provider 27 9

25 Job Analysis Survey of 7 practices Extensive interview of provider, nurse, pharmacist, clerk (1 to 2 days) Standardized description of tasks 243 tasks identified 26 Task Categories

10 Who COULD Do Task? Doc Nurse Clerk Administrative Y Y Y Prevention Y Y P Treatment Y P N Diagnosis Y P N Relationship Y P N 28 Who SHOULD Do Task? Doc Nurse Clerk Administrative N N Y Prevention P Y P Treatment P P N Diagnosis Y P N Relationship Y P N 29 Impact of Task Reassignment Positive Considerations Increase capacity of expensive resource Save $ Clarify roles in team Negative Considerations Pain of change Match of job with individual preferences and talents? 30 10

11 Task Reassignment: The 4 Ts Task Team Timing Terrain 31 Task Reassignment Examples Assistance with undressing for exam Vital signs Phone answering 32 Perspective # 1 From the view of the current job category and the work done 33 11

exam Vital signs Phone answering 32 Perspective # 1 From

12 Tasks by Job Category RN MD Clerk/Scheduler 34 WW - Workload Analysis Cycle 2 (Minutes) 1,118, 6% 5,632, 28% 10,765, 53% 2,545, 13% Direct Activity Indirect Activity Non Patient/Provider Related Activity Travel 35 Non Patient/Provider Related Activity 3% 0% 2% 4% 3% 6% 2% 12% 19% 6% 3% 1% 1% 7% 2% 6% 5% 18% Conference Inservice Research/ Lit Review Educational Resource Development Quality Improvement to Current Resources Meetings Meeting Preparation Informal Conversations Mileage Form Completion Timesheet Completion Staff Activity Report Completion Committee Work Reading/ Writing Providing Orientation Receiving Orientation Team Lead Scheduling: Staff / Service Staff Scheduling: Outlook/ Webview Other 36 12

Educational Resource Development Quality Improvement to Current Resources Meetings Meeting Preparation Informal Conversations Mileage Form Completion Timesheet Completion Staff

13 Perspective #2 From the view of the task itself 37 What is the Work? Who is/should be doing it? Task Clerical MA RN Provider Registration Rooming Refills Advice Order Entry Med. monitoring Teaching 38 Work Analysis Example Task/Process Who does it now In a perfect world who would do it Book appointments Nurses Clerical support Take incoming calls Providers Clerical support Chart prep Triage Med refills Financial authorization Etc 39 13

monitoring Teaching 38 Work Analysis Example Task/Process Who does it now In a perfect world who would do it

14 Work Analysis Worksheet by Task Task/Process Who does it now? In a perfect world who would do it? 40 Team Exercise Step 1: Using the Process Survey Worksheet, rate your current office processes Step 2: Choose one of the problem-some processes identified and map this process using the Flowchart Worksheet Step 3: Using the Task Worksheet, list all the tasks associated with the mapped process and identify who does it now and who could/should do it Step 4: Refer to the considerations for task analysis (on the next slide) 41 Considerations for Completing Task Analysis Identify all tasks What can be eliminated? Combined? Identify who currently does these tasks Should they be doing them? Are all working to their highest level? In a perfect world, who would/could/should do these tasks? What is the plan to deliberately move toward that ideal? 42 14

Worksheet Step 3: Using the Task Worksheet, list all the tasks associated with the mapped process and identify who does it now and who could/should do it Step 4: Refer to the considerations for task

15 What did you learn? 43 15

Medical Assistants: Embracing New Roles

Summit 2011 LEARN SHARE TRANSFORM Medical Assistants: Embracing New Roles Catherine Tantau, BSN, MPA Tantau & Associates Session 1C March 7, 11:00AM-12:30PM Develop Team Work 2 2 Objectives Learn the Golden